Just a little over sixty years ago (January 14, 1949), Harry Stack Sullivan died of a persistent cardiovascular disease while attending an international conference, the World Federation for Mental Health, in Paris where his life’s work was being critically and enthusiastically touted as a major contribution to a deepening understanding of psychotherapy in the modern world. Following in the wake of Freud, Jung, and Adler, Sullivan stepped forward with both an appreciation of the psychoanalytic tradition and a readiness and willingness to reach across disciplines to the social and behavioural sciences to deepen his understanding of the complexities of mental illness as related to interpersonal relationships and particularly to schizophrenia. This willingness to venture out has resulted in Sullivan being acclaimed by many as the “father of modern psychiatry“ [1-3] and by others as an interdisciplinary innovator worthy of international acclaim in mental health treatment [4].

Born of poor Irish Catholic farming parents in upper New York State in February, 1892, amidst many Protestants and few Catholics, Sullivan had no siblings and lived a solitary life and a precocious child until the age of sixteen when he enrolled in Cornell University with a State scholarship in 1908. “Brilliant and taciturn“ as he was, his ambition drove him to successfully seek admission into the chartered, but somewhat dubious, Chicago College of Medicine and Surgery in 1911 where general medicine was the curriculum with no psychiatry to be found.

Gaining the medical diploma in 1917, he bounced around from one hospital to another where, by sheer dent of determination, he worked with the mentally ill patients, and particularly schizophrenics, employing a method he early on labeled “interpersonal therapy.“ Two years in medical practice with the U.S. Army landed him a position at the prestigious St. Elizabeth’s Hospital in Washington, D.C., where, without any previous training in psychiatry other than what he had taught himself, he was invited to work with the notable Freudian psychiatrist, William Alanson White, M.D. Whether it was the luck of the Irish or his own tenacity and self-confidence, Sullivan was also made a clinical researcher at Sheppard and Enoch Pratt Hospital and subsequently named to the faculty of the University of Maryland’s School of Medicine.

During what he in later years looked back on as his “Baltimore period,“ he began to research, write, and speak about his therapeutic treatment of the mentally ill, particularly schizophrenia, and thereby built a reputation which resulted in his being called to the Washington School of Psychiatry as staff faculty and chairman of the Council of Fellows and editor of the School’s internationally distinguished journal, Psychiatry. As with other great innovators in the sciences, Sullivan’s fortuitous and profoundly beneficial acquaintances with some of the leading social scientists of the day became the basis upon which he furthered his interest in interpersonal relationships as a key to mental health [5]. Such collegial associates as Edward Sapir, a cultural anthropologist and Harold Lasswell, a political scientist, of the University of Chicago wielded great influence upon Sullivan’s interest in the behavioral sciences, as did his personal acquaintances with George Herbert Mead, Robert Ezra Park, and W. I. Thomas, the internationally distinguished sociologists of the time all teaching at the University of Chicago. Finally, in New York City where he had established a very successful private practice, his friendships with the outstanding psychologists of the day, Erich Fromm, Frieda Fromm-Reichmann, and Adolf Meyer proved crucial to his final developmental stages of theory-building [6].

In 1939, the William Alanson White Foundation decided that a series of lectures should be given to honor the memory of White, a colleague of Sullivan’s, who had died in 1937, and, of course, Sullivan was chosen to give the first series. He actually gave five lectures to an enthusiastic group of professionals in an auditorium owned by the Department of the Interior in Washington, DC. In these lectures, Sullivan made his first public attempt to present both a comprehensive and well-thought-out explanation of his concept of personality development including psychiatric disorders and treatment. In February of 1940, they were all published in the journal, Psychiatry, at the insistence of Sullivan’s friends and colleagues, but against his best judgment. He was not pleased with his performance but finally consented and they appeared. Not surprisingly, they attracted much attention within the psychiatric and social science communities and in the following years many mental health and social science professional workers wrote to secure copies of this issue of the periodical. Finally, in 1947, much to the chagrin of Sullivan who believed his presentation of his thoughts was “grossly inadequate,“ a new printing of these lectures came out again in Psychiatry. This was a hardback edition and carried the somewhat dubious title of Conceptions of Modern Psychiatry [7]. This was actually his only book, at least in his lifetime, to see the light of day though several subsequent volumes of his lectures and essays, all touted to be Sullivan’s books and finally appeared. This one, however, sold 13,000 copies over the next several years and the William Alanson White Foundation gained considerable attention because of them. Under the same title, this book was published again four years after the death of Sullivan and it still sells well today. Sullivan, however, denounced many of the premature conceptual developments in the work and discounted its value.

Nevertheless, it is a pivotal work for our consideration and a few remarks are justified before we move to the fundamental concepts and theories of Sullivan’s notions of personality.

“Psychiatry,“ Sullivan wrote, “is the study of processes that involve or go on between people. The field of psychiatry is the field of interpersonal relations, under any and all circumstances in which these relations exist“ [7]. This is the thesis set forth by Sullivan in this book. It is the first place where he expressed the central ideas of his theory of personality. Through his development of the theory, he made not only a vital contribution in the treatment of mental disorder -- in particular, schizophrenia [8] -- but he opened an entirely new approach to the study of human personality (Sullivan, 1953b). In the view of many analysts, he made the most original contribution to psychiatry since Freud. Rollo May has gone on record as saying, “As Freud was the prophet for the Victorian age of sexual suppression, Sullivan is the prophet for our schizoid age -- our age of unrelatedness, in which, beneath all the chatter of radio and newspapers and all the multitudes of ‘contact,’ people are often strangers to each other“ [1].

In this work, he created a new viewpoint which is known today as the “interpersonal theory of psychiatry.“ Sullivan’s fundamental emphasis related to a theory of personality which is a “relatively enduring pattern of recurrent interpersonal situations which characterize a human life“ [9]. Radically shifting from the psychoanalytic focus on the unconscious, Sullivan brought to his clinical research and practice a behavioral and social science perspective which had not been considered a significant component of personality theory until he did it [10]. He argued that the concept of “personality“ is itself a hypothetical entity which cannot be isolated from interpersonal situations and, indeed, interpersonal behavior is all that is observable about personality. The rest, he suggests, is strictly metaphorical speculation and creative imagery. It is futile and fruitless to speak of a person’s personality outside the social interactive matrix of the living person. Not discounting the significance of heredity and the maturation process as affected by the physical environment, the real thing that determines the nature of a human person is the social interaction of that person with others [8].

Never before had such an attempt been made to merge psychiatry and social psychology [11]. His theory of personality is the product of such a merger and it is greatly enriched by his acquaintance with and utilization of the social sciences. He writes: “The general science of psychiatry seems to me to cover much the same field as that which is studied by social psychology, because scientific psychiatry has to be defined as the study of interpersonal relations, and this in the end calls for the use of the kind of conceptual framework that we now call field theory. From such a standpoint, personality is taken to be hypothetical. That which can be studied is the pattern of processes which characterize the interaction of personalities in particular recurrent situations or fields which include the observer“ [10]. This attitude about the place and relevance of the “observer“ in the clinical situation became a benchmark of Sullivan’s innovative approach to the therapeutic encounter. He was, of course, influenced by the science philosopher, Heisenberg, on this point particularly [12].

Modern psychiatry, as defined and practiced by Sullivan, consists of a study of personality characteristics which can be directly observed in the context of interpersonal relationships [13]. Systems of psychiatry based on statements about what is going on in the patient’s mind are therefore similar to a system of thought which is built on axioms such as “All events are controlled by Divine Providence.“ The truth or falsehood of this statement cannot be established by things that reasonably well educated people can see, hear, and feel. Much human experience can be cited to support such a statement, and much human experience can be cited to nullify it, but it is so set up that it must always remain a matter of faith. For Sullivan, a “personality characteristic“ is defined as the things which people can see, hear, and feel in their relationships with other individuals. This is the most fundamental working hypothesis in his personality theory [14].

Though Sullivan is only willing to allow personality to be purely hypothetical apart from the actually observable reality of social interaction, he does assert that it is a dynamic center of various processes which occurs in a series of interpersonal fields. This “dynamism“ is a key concept in his overall personality theory [15]. He gives significant place to these processes by identifying and naming them as he constructs a platform of their characteristics. These processes, then, are dynamisms, personifications, the self-system, and cognitive processes. Let’s explore each briefly here as they constitute the backbone of his major work, Conceptions of Modern Psychiatry [7].

The smallest unit of study in interpersonal relationships is what he calls “dynamism“ [9]. It constitutes an energy transference which means any unit of behavior, either actual act or mental experience. These become habitual ways of acting which involve the physical body of the person, such as the mouth, hands, arms, legs, etc. These dynamisms can then be broken down into a plethora of subsets, such as the fear dynamism, intimate dynamism, etc. the dynamisms which are distinctively human in character are those which characterize one’s interpersonal relations and function primarily to satisfy some basic needs of the individual. Three major dynamisms are malevolence, lust, and intimacy. Malevolence is the driving dynamism that one is living among one’s own personal enemies and, if this negative dynamism emerges early in a child’s life, he may find it difficult ever in adulthood to reach a fully trusting relationship with another person. Sullivan expressed it poignantly: “Once upon a time everything was love, but that was before I had to deal with people“ [7]. Lust is another driving dynamism of the individual. Lust for Sullivan consists of the complex urges, feelings, and interpersonal actions which have genital sexual activity as their distant or immediate goal and lust begins in early adolescence. Sullivan rejected the Freudian concept of sexuality and suggested that it was more or less inconsequential in childhood and early adolescence, but lust constitutes a major driving force in later adolescence. Intimacy for Sullivan is a profoundly positive dynamism potentially. It occurs when the well-being of another person is as important to an individual as his own well-being. It does not occur in parent-child relationships and does not involve lust or sexual behavior. It occurs only between members of the same sex. Lust becomes, then, a “contaminant of intimacy“ for lust seeks to serve itself rather than the other person.

Personifications consist of an image that an individual has of himself or of some other person. It is a complex of feelings, attitudes, and conceptions that grows out of experience with need-satisfaction and anxiety and, for example, Sullivan speaks often of the “good-mother,“ “bad-mother,“ and “overprotective mother“ as examples [13]. When these personifications are shared by a large social grouping, they become stereotypes such as “all Irishman are drunks,“ “all Catholics lie,“ etc., and these stereotypes are held by social groups without experience of their reality but of a shared personification of imagined behavior among peoples not personally known.

The self-system is another dynamism which is crucial to personality structure. It functions as a security measure to protect the individual from anxiety. In order to avoid or minimize actual or potential anxiety, the person adopts various types of protective measures and supervisory controls over his behaviour. These security measures form the self-system which sanctions certain forms of behaviour, such as the “good-me“ self, and forbids other forms of behaviour, such as the “bad-me“ self.

Sullivan’s unique contribution to the role of cognition in personality theory has to do with his development of a threefold classification of experiences, for, says he, experiences occur in three different modes -- protaxic, parataxic, and syntaxic [9]. These experiential modes merit a brief description in order to appreciate their relevance to Sullivan’s interpersonal relations’ description of psychiatry. Sometimes called “types of experience“ and sometimes called “types of cognition,“ this tripartite foundation of personality encounters are worthy of close attention.

The simplest and most fundamental mode of experiencing reality at the beginning of life is what Sullivan chose to call the prototoxic mode. It consists of essentially a flowing of sensations, feelings, and images without any necessary connection between them, a kind of “stream of consciousness,“ if you will. Sullivan himself describes it this way: “It may be regarded as the discrete series of momentary states of the sensitive organism“ [9]. It occurs, of course, during the earliest months of infancy and must precede the others as a preparation for them. The parataxic mode of thinking, Sullivan explains, consists of seeing causal relationships between events that occur at about the same time but which are not logically related. Getting the connection wrong is what this mode of experience is all about. It is magical thinking, says he, for there is no logical connection between two events experienced by the child in which the child assumes there is. It is essentially the “elementary externalization of causality.“ In childhood it occurs regularly when the child assumes that something he has done is the cause of something that is quite decidedly unrelated but he thinks it is. In adulthood, the residuals of parataxis modes of experiencing occur in such things as the presumed relationship between “praying hard“ and “getting well.“

Finally, the third and most advanced mode of experience is called syntaxic and it corresponds to logical, analytical thought. Syntaxic experience of reality thus presupposes the ability to understand physical and spatial causality, and the ability to predict causes from knowledge of their effects. The meaning of words and the use of numbers constitute the most poignant examples of the function of syntaxic experience and when the child learns the meaning of specific words and their uses and the nature of numbers and how they work, the child has reached this level of experiential sophistication needed in the development of interpersonal relationships.

Harry Stack Sullivan’s distinguishing contribution to contemporary psychiatry was his heavy emphasis upon the social factors which contribute to the development of human personality [16]. Though schooled in Freudian psychoanalysis, he was not a traditional Freudian for he differed from Freud in viewing the significance of the early parent-child relationship as being an early quest for security rather than, as in classical psychoanalysis, primarily sexual in origin and nature.

Drawing from his own personal life’s story, Sullivan saw this child-mother relationship as central, not the sexual drive of libidinal instincts. Sullivan was intent upon integrating the multiple disciplines of the behavioral and social sciences into the work of psychiatry such that sociology and social psychology in the tradition of George Herbert Mead and Charles Horton Cooley proved most helpful in Sullivan’s eventual development of what became known as interpersonal psychiatry, later interpersonal psychotherapy [10]. He was not averse to reaching across disciplinary lines for theory and method, from evolution to communications, from learning theory to social organization. It was “interpersonal relations“ which, he believed, constituted the fundamental ingredient in the personality structure.

Sullivan was averse to that form of psychiatry and clinical psychotherapy which dealt with mental illness through the study of institutionally-isolated patients. He had extensive experience in working with the mentally ill, particularly with schizophrenics, and he felt the institutionally committed constituted a weak source of clinical insight [8]. Personality characteristics, for instance, he felt were determined by the interpersonal relationships between therapists and patients and that the institutional environment was artificial and counterproductive. Sullivan contended that personality develops according to people’s perception of how others view them. “Others,“ in Sullivan thought, included personifications, like the government, as well as imaginary and idealized figures like Jesus or Moses or even movie stars. He believed, based upon his own clinical encounters with severely mentally ill patients, that cultural forces were largely responsible for their psychological condition [15]. He contended that a healthy personality is the result of healthy relationships and that most of what goes in our society as mental illness is not “biogenic,“ but rather “sociogenic.“ Sullivan refused to employ the concept of “personality“ as a unique, individual, and unchanging entity as so often was the case with traditionalists. He much preferred to define personality as a manifestation of the interaction between individuals, namely, interpersonal relations [9].

Sullivan’s clinical work in a variety of settings through several years of medical assignments led him to believe firmly in the impact interpersonal relationships have upon personality development. He noted that individuals tend to carry distorted views and unrealistic expectations of others into their relationships. His solution was to become, as a clinical psychotherapist, a “participant observer“ in dealing with his clients, taking a more active therapeutic stance than the traditional psychoanalytic “blank screen“ approach popular at the time, particularly with traditional psychoanalysis. By focusing upon what he called “interpersonal behavior,“ he would observe the client’s reaction to the therapist and the therapeutic environment. He believe that emotional well-being could be achieved by making an individual “aware“ of their dysfunctional interpersonal patterns of interaction and thereby grow into a healthy self-awareness of their interactive behavior.

Before we consider Sullivan’s now paradigmatic stages of personality development, we should say something about his concept of human nature and, it has been suggested by him many times, it can be summed up in the expression, “everyone is much more simply human than otherwise“ [7]. Having made this his standard operational modality, he utilized it throughout his career and summed up its meaning this way: “In other words, the differences between any two instances of human personality from the lowest grade imbecile to the highest-grade genius -- are much less striking than the difference between the least-gifted human being and a member of the nearest other biological genus.“ Sullivan was outspoken on this point.

Denying that there were any really operative instincts left in the human person, and thus separating himself profoundly from the classical school of psychoanalysis, Sullivan contended that it is the social environment in which we mature that determines the effectiveness of our maturation. Interpersonal relationships are the essence of human development. We are only human in so far as we develop within the context of other people. We need to learn to compete, cooperate, and compromise with others as we mature in order to maintain mental health. He concluded, therefore, that personal individuality is an illusion. We exist only in relationship to other people. When we mature within a healthy social environment, this positive progression of interpersonal events leads to an integrated personality, to an adult who is capable of establishing satisfying interpersonal relations and who is able to both give and receive love. This is the essence of the human personality.

Sullivan’s elaborate and well-developed description of the stages of human development were reminiscent of Freud’s schematic system. But, whereas Freud built his developmental scheme around the central core of childhood sexuality, Sullivan built his around the fundamental core of interpersonal relationships. There are seven developmental stages in his schema and we will just mention them briefly here before concluding with remarks about his therapeutic method. Infancy is from the beginning to about eighteen months and the first expressions of the “self- system“ appear when the infant encounters and relates to the “good me“, “bad me“ feeding experience in relationship to his mother. Childhood commences with the acquisition of language and goes through the preschool years. Syntaxic experience develops and the child encounters and deals with the reality and necessity of living with others as peers and authority figures. The juvenile person corresponds to the grade school years to about age eleven and here interpersonal relations includes competition, cooperation, and comprise as developmental necessities. Preadolescence is short, eleven to thirteen more or less, and here intimacy emerges in relationship to same-sex peers and chums and marks the first real instance of what Sullivan calls “genuine human relations.“ Early adolescence commences the heterosexual years of stress and physical development and the intimacy dynamic is matched with lust and lasts through the beginning of the high school years when late adolescence produces the profound demands of complex interpersonal relationships and particularly heterosexual ones fraught with anxiety. Adulthood arrives with the composite of strengths and weaknesses in the personality which has developed through the interpersonal experiences of the maturing process.

Sullivan’s psychotherapeutic methodology was quite unique to his own understanding of the function and nature of interpersonal relationships. Sullivan firmly believed, based upon his extensive clinical experience, that mental disorders derive from interpersonal failures and, therefore, therapeutic procedures must be based upon a genuine effort to improve the patient’s relationship skills in dealing with others [13]. In keeping with his overall worldview, he believed that interpersonal relationships constitute the core of psychotherapeutic treatment. In this situation, it is imperative that the therapist understand that his role is primarily that of a “participant observer,“ for, despite all protestations to the contrary from traditionalists, the therapist becomes necessarily part of an interpersonal, face-to-face relationship with the patient. This process actually creates the opportunity for the patient to establish a syntaxic communication with another person, namely, the therapist himself.

Because of the emphasis upon the therapeutic role being that of an “observer,“ the therapist is exempt from becoming “involved“ with the patient but, as with the Freudian tradition, the therapist must establish a relationship based upon his role as an expert in relationships, not just a friend, chum, or colleague. Unlike the work of Carl Rogers, Sullivan is insistent that the therapist “not“ become a friend of the patient, thereby destroying the “observational“ character of the therapist’s relationship to the patient. Sullivan had three primary objectives in the therapeutic situation [14]. First, he intends to help the patient improve foresight, discover difficulties in interpersonal relations, and restore the ability to participate in consensually validated experiences. This occurs when three questions are addressed: (1) How can I best put into words what I wish to say to the patient, (2) What is the general pattern of communication between us, and (3) What precisely is the patient saying to me. Simplistic? Certainly not!

The therapeutic interview is divided into four stages: (1) formal inception, (2) reconnaissance, (3) detailed inquiry, and (4) termination. Let’s explicate just briefly the character of each stage. At the first meeting, the psychiatrist promotes confidence in the patient by demonstrating interpersonal skills and permit’s the patient to express the reasons for seeking therapy in the first place. The therapist, then, formulates tentative hypotheses regarding the declared cause for seeking treatment, and then decides on a possible course of action.

During reconnaissance, there is a general personal and social history established of the patient and the therapist who attempts to determine why the patient came to develop a particular personality type. Here, the therapist asks specific questions about the patient’s age, birth order, mother, father, education, occupational history, marriage, children, etc. Open ended questions are asked to invite the patient to feel free to express the patient’s emotional state at the time. Then, the detailed inquiry attempts to improve upon the therapist’s understanding of the patient and the patient’s understanding of the patient’s own situation, particularly articulating why the patient has sought therapy. The fourth and final stage of the interview is termination, or, in some cases, interruption. Of course, this means that the interview has come to an end. Quite commonly, the therapist gives the client “homework,“ something to do or some memory to recall for the next session. After each session, the therapist makes copious notes about the session, what progress has been made and what issues have arisen that need addressing in the next session. For Sullivan, the therapeutic ingredient in this process is the face-to-face relationship between psychiatrist and patient, which permit’s the patient to reduce anxiety and to communicate with others on the syntaxic level.

From Freud to Sullivan is not only a monumental leap in time but a quantitative leap in personality theory and psychotherapeutic theories of practice [17]. From the birth of Freud in 1856 to the death of Sullivan in 1949, the world of psychology and the practice of both psychiatry and psychotherapy have undergone a development comparable to that in biology and physics in the last hundred years. From Freud’s fascination with the possibilities of exploring the “unconscious“ of a patient through the use of dream interpretation, word associations, and hypnosis to Sullivan’s clinically-demonstrated insight into the fundamental nature of interpersonal relationships skills as the determiner of mental health, one can argue that the discipline of psychology has remade itself. From deterministic behaviorism to the Third Force is no easy leap and with the initial and somewhat overpowering influence of the “depth“ psychologists, Freud and Jung, the gradual emergence of the humanistic school of psychotherapy under the leadership of such clinical practitioners as Maslow, Frankl, and Rogers is nothing short of profound [18].

Interpersonal psychotherapy arrived upon the scene just when it seemed that “depth“ psychology of the psychoanalytic type was waning in terms of both interest in and viability for those in the diverse fields of counseling. Certainly the arrival of Viktor Frankl’s “will to meaning“ followed by the humanistic Third Force movement has reinvigorated counseling psychology like no previous theoretical development in the history of the field. Not only Rogerian client-centered therapy and Sullivan’s interpersonal psychotherapy have also shared in this resurgence of professional interest in counseling psychology and all signs indicate that they will continue to do so.